Letter to the Editor Ischemic stroke mimicking acute myocardial infarction, a diagnostic dilemma

Case report A 63-year-old man was found in a comatose state. His medical history revealed hypertension, hemorrhagic stroke, and epilepsy. Neurological examination showed a Glasgow Coma Score (GCS) of E1M4V1, horizontal conjugated left- sided gaze deviation, and myoclonic jerks in the face. Further physical examination was normal. The electro- cardiogram (ECG) showed a sinus tachycardia of 140 beats/min, intermediate heart axis, and ST elevations in I, II, AvF, and V2-V6 leads. Echocardiography demonstrated severe impaired left ventricular function with wall motion abnormalities (WMA) in the inferoseptum, and ballooning of the apex. Cardiac enzymes were elevated with a troponin T of 0.64 Ag/l (normal <0.01 Ag/l). Initial brain computer tomography (CT) revealed no signs of hemorrhage or acute ischemia. Because of suspected anterior wall myocardial infarction, coronary angiography (CAG) was performed, demonstrating TIMI 3 flow in all coronary arteries. Nevertheless, ST elevations were still present during CAG. After admission, a drop in blood pressure and a decrease in cardiac output occurred, which responded well to inotropics. In the following days, medication was decreased, and serial ECG showed gradual improvement (Fig. 1). Echocardiography 9 days later showed mild hypokinesia remaining in the apex. A repeat brain CT demonstrated infarction of the right medial and posterior cerebral artery territories.